Provider Demographics
NPI:1366442741
Name:SOUTH FAYETTE NURSING CENTER, LP
Entity Type:Organization
Organization Name:SOUTH FAYETTE NURSING CENTER, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-431-0770
Mailing Address - Street 1:252 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARKLEYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15459-1202
Mailing Address - Country:US
Mailing Address - Phone:724-329-4830
Mailing Address - Fax:724-329-1503
Practice Address - Street 1:252 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARKLEYSBURG
Practice Address - State:PA
Practice Address - Zip Code:15459-1202
Practice Address - Country:US
Practice Address - Phone:724-329-4830
Practice Address - Fax:724-329-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA453602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
10360OtherGATEWAY HEALTH PLAN
PAPENDINGOtherHIGHMARK BC
PA1019298830001Medicaid
PAPENDINGOtherHIGHMARK BC